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Tag No.: A0115
Based on video surveillance review, document review and interview, it was determined that the Hospital failed to comply with the Condition of Participation 42 CFR 482.13 Patient Rights.
Findings include:
1. The Hospital failed to ensure that patients were free from abuse, by not initiating an investigation upon notification of an abuse allegation. See deficiency at A-145 (A).
2. The Hospital failed to follow the procedure for responding to abuse allegations, by not removing the alleged staff, from the Hospital, as required. See deficiency at A-145 (B).
An immediate jeopardy (IJ) investigation was conducted on 12/19/2024 through 12/26/2024 for complaint #IL00182769/2421583. The immediate jeopardy began on 12/9/2024, due to the Facility's failure to initiate an investigation upon notification of a physical abuse allegation and failed to suspend alleged staff members following the notification of the allegation, that led to IJ. The IJ was identified on 12/26/2024 at 42 CFR 482.13 Patient Rights. The IJ was announced on 12/26/2024 at 5:00 PM, during a meeting with the Senior Vice President of Patient Care; The Executive Vice President; and the Director of Quality and Risk, and was not removed by the survey exit date of 12/26/2024.
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Tag No.: A0145
A. Based on document review, video surveillance review, and interview, it was determined that for 1 of 4 (Pt #1), clinical record reviewed for abuse, the Hospital failed to ensure that a patient was free from abuse, by not initiating an investigation, upon notification of a physical abuse allegation..
Findings include:
1. The Hospital's policy titled, "Resolution of Patient Complaints and Grievances (dated 6/13/2022), was reviewed and required, "...Procedure: 1. Any allegations of abuse must be escalated and investigated immediately in accordance with [Hospital] Abuse and Neglect Policy. To resolve an issue as soon as possible any staff member that is aware of a concern should notify their supervisor or manager..."
2. The Hospital's policy titled, "Incident Reporting" (dated 6/2024), was reviewed and required, "A report of Unusual Incident Form must completed for all accidents/incidents occurring to patient on hospital property..."
3. There was an event summary regarding Pt #1's event, that was documented by the Nursing Supervisor (E #3). However, there was no formal incident report initiated by E #3. The event summary included. " ...Incident Summary: [E #1] was handcuffed and arrested by [local police department] for alleged battery of a male psychiatric patient. The arrest was based on a report by an EMT [emergency medical technician] employee from [ambulance company], who claimed to have witnessed the incident. [EMT] stated that [E #1] was arguing and verbally aggressive with patient [Pt #1] while trying to get the patient to take a bath. [Nurse/E #6] reported that the patient was the aggressor and that [E #6] did not witness [E #1] assaulting the client. After reviewing the footage, the Director of Security [E #2] found the allegations to be false. Response and Actions: CNO [E #4], and [E #2] were notified; ER Nurse [E #9], Receiving Nurse [E #6], and Supervisor [E #3] assessed the patient for injuries, followed by the resident doctor; No injuries were reported by the on-call resident ..."This event summary was reported to tE #4, E #2, and E #8. However, it was not escalated to the Risk Department, as required per policy.
4. The clinical record for Pt #1 was reviewed on 12/23/2024. Pt #1 was a direct admit to 4 East (Adult Male Behavioral Health) Unit on 12/9/2024. Pt #1 was discharged home on 12/15/2024.
- The Initial Psychiatric Evaluation (dated 12/9/2024), documented by the Attending Psychiatrist (MD #1), included, "[Pt #1] with a longstanding history of very poorly controlled diagnosis of schizoaffective disorder [serious mental illness].
- A Nursing admission note (dated 12/10/2024 at 2:05 AM), documented by the 4 East Registered Nurse (RN/E #6), included, "Pt arrived [to] the unit at 0040 [12:40 AM] on a stretcher [accompanied] by [Hospital transporter] and security. Pt is a direct admit from [a local hospital]. Pt is involuntary admission and petitioned. Pt was taken to 4 Main [an unoccupied unit] to clean up because per report, pt has lice and bedbugs ...Per protocol with pt with bed bugs and lice, pt should shower with medicated soap ...before the pt can be admitted to the unit. Pt is violent toward staff and difficult to follow instruction to shower ...pt is aggressive and extremely violent towards others .... No physical injuries noted on pt."
- A General note (dated 12/10/2024 at 6:19 AM), documented by a Resident Physician (MD #2), included, "I [MD #2] was called by the nurse at 5:05 am to assess the patient [Pt #1] after [Pt #1] was physically hit by a security guard at the hospital during admission. Nurse stated that EMS personnels witnessed the incident and called the police who came to the hospital and made the report. On encounter, patient was sleeping and no signs of bruises and denies any pain."
5. On 12/23/2024 at 11:55 AM, video footage of the incident regarding Pt #1's incident on 12/10/2024, was reviewed with the Director of Public Safety (E#2). The identity of the persons in the video footage were confirmed with E #2 and the Behavioral Health Director (E #8). The footage was from the 4 Main hallway, on 12/10/2024 at 12:39 AM-1:07 AM. Due to the angle of the footage, unable to get a direct view into the shower room. The following was noted on the footage. At 12:39 AM, Pt #1 was brought to the 4 Main unit, by the EMS, and a Nurse Tech (E #9) via stretcher. At approximately 12:40 PM, Pt #1's admitting nurse (E #6), was seen walking in the hallways. At 12:42 AM, Pt #1 walked into the shower room, with 1 EMT remaining in the hallway (no staff at that time). At 12:48 AM, the 2 security officers (E #1, E#7), a Nurse Tech (E #9), and the 2nd EMS re-entered the unit, while Pt #1 remained in the shower. At 12:48:28, Pt #1 comes to the entrance of the shower door and has verbal interaction with the 2 officers (E #1, E #7) and the nurse (E #6). At 12:48:44, E #1's left arm went towards the shower door in a pushing motion, and then E #1's right arm went towards the shower room in a striking motion (from the angle of the camera view, was unable to determine if any physical contact was made). At 12:48:55 AM, the 2 EMTs left the unit, while Pt #1 remained in the shower room. At 12:49:08 AM, both E #1 and E #7 re-entered the shower room where Pt #1 was still present (without clinical staff). At 12:50:10 AM (approximately 1 minute later), the 2 officers (E #1 and E #7), exited out of the shower room. At 1:07:33 AM, Pt #1 ambulated out of the shower room and was escorted off 4 Main to 4 East (admitting unit) by the 2 officers (E #1, E #7), and the nurse tech (E #9).
6. The Incidents logs from 10/2024-12/23/2024, were reviewed. The log did not include any incidents or investigation regarding Pt #1. On 12/23/2024 at approximately 1:00 PM, an interview was conducted with the Director of Quality and Risk (E #5). E #5 stated that E #5 was not made aware of the incident involving Pt #1 and E #1. E #5 stated that, therefore, there is no incident report or investigation, from the Quality and Risk department.
7. On 12/23/2024 at 10:55 AM, an interview was conducted with the Director of Security (E #2). E #2 stated that when there is a security incident, E #2's department completes a security incident report. E#2 stated that security incidents are then escalated to the nursing department and to the Risk department. E #2 stated that E #2 did escalate Pt #1's incident to the nursing supervisor (E #3).
8. On 12/23/2024 at 2:10 PM, a phone interview was conducted with the Public Safety Officer (E #1). E #1 stated that E #1 wrote up a report regarding the incident with Pt #1. E #1 stated, however, there has been no follow-up communication from administration, regarding the incident.
9. On 12/24/2024 at 8:55 AM, an interview was conducted with the Nursing Supervisor (E #3). E #3 stated that E #3 was told by an ER nurse that a security officer was arrested and detained at the local police station. E #3 stated that at that point, E #3 interviewed the EMT staff that was still present in the Hospital (the staff that transported Pt #1 and alleged witness abuse to Pt #1). E #3 stated that after E #3 received this report, E #3 called the Director of Security (E #2); the Senior Vice President of Clinical Services (E #4), and the Director of Behavioral Health (E#8). E #3 stated that, regarding the incident with Pt #1, it could be classified as an abuse allegation. E #3 stated that E #3 wrote up an event summary for Pt #1. E #3 stated that, however, E #3 did not write a formal incident report and the incident was not escalated to the Risk Department.
10. On 12/24/2024 at 1:40 PM, a phone interview was conducted with the EMT (Z #2/transferred Pt #1). Z #2 stated that Pt #1 was transferred from another hospital due to behaviors. Z #2 stated that when Pt #1 was transported onto the unit (4 Main), Pt #1 was verbally aggressive, but not physically aggressive. Z #2 stated that Z #2 was able to see into the shower room, where the door was still open. Z #2 stated that Z #1 (the other EMT) and Z #2 witnessed a security guard hit Pt #1 and the patient went down to the floor. Z #2 stated that a nurse was trying to break up the encounter. Z #2 stated that after Z #1 and Z #2 left the unit, they called the Medical Control, and they were advised to call the police.
B. Based on document review and interview, it was determined that for 2 of 4 (Pt #1, Pt #2) clinical records reviewed for abuse, the Hospital failed to ensure that the procedure for abuse allegations, was adhered to, by failing to remove staff upon notification of an abuse allegation.
Findings include:
1. On 12/24/2024, the Hospital's policy titled, "Abuse-Clients and/or Family Members with Grievance Regarding Physical or Sexual Abuse or Neglect" (dated 10/2024), was reviewed and indicated, " ... If the grievance is made against the employee, the employee will be placed immediately on indefinite suspension ... pending an investigation ... Informs the patient/of his/her rights to contact the police and file a complaint ..."
2. An event summary regarding Pt #1, that was documented by the Nursing Supervisor (E #3), included. " ...Incident Summary: [E #1] was handcuffed and arrested by [local police department] for alleged battery of a male psychiatric patient. The arrest was based on a report by an EMT [emergency medical technician] employee from [ambulance company], who claimed to have witnessed the incident. [EMT] stated that [E #1] was arguing and verbally aggressive with patient [Pt #1] while trying to get the patient to take a bath. [Nurse/E #6] reported that the patient was the aggressor and that [E #6] did not witness [E #1] assaulting the client. Response and Actions: CNO [E #4], and [E #2] were notified; ER Nurse [E #9], Receiving Nurse [E #6], and Supervisor [E #3] assessed the patient for injuries, followed by the resident doctor; No injuries were reported by the on-call resident ..."
3. The clinical record for Pt #1 was reviewed on 12/23/2024. Pt #1 was a direct admit to 4 East (Adult Male Behavioral Health) Unit on 12/9/2024. Pt #1 was discharged home on 12/15/2024.
- The Initial Psychiatric Evaluation (dated 12/9/2024), documented by the Attending Psychiatrist (MD #1), included, "[Pt #1] with a longstanding history of very poorly controlled diagnosis of schizoaffective disorder [serious mental illness].
- A Nursing admission note (dated 12/10/2024 at 2:05 AM), documented by the 4 East Registered Nurse (RN/E #6), included, "Pt arrived [to] the unit at 0040 [12:40 AM] on a stretcher [accompanied] by [Hospital transporter] and security. Pt is a direct admit from [a local hospital]. Pt is involuntary admission and petitioned. Pt was taken to 4 Main [an unoccupied unit] to clean up because per report, pt has lice and bedbugs ...Per protocol with pt with bed bugs and lice, pt should shower with medicated soap ...before the pt can be admitted to the unit. Pt is violent toward staff and difficult to follow instruction to shower ...pt is aggressive and extremely violent towards others .... No physical injuries noted on pt."
4. On 12/24/2024, the clinical record for Pt #2, was reviewed. On 12/9/2024 at approximately 12:43 PM, Pt. #2 was brought to the hospital's ED (emergency department) due to bizarre and paranoid behavior:
- At 1:10 PM, the ED nurse's note indicated, "RN (registered nurse) called to room and security holding (Pt. #2) ... blood noted to (Pt. #2's) bottom lip ..." The note did not indicate how Pt. #2 sustained injury to bottom lip.
- At approximately 9:05 PM, Pt. #2 was admitted to the behavioral health unit. The admitting nurse's note indicated, " ...received on the unit ... ambulatory ... injuries mild healing stage noted on (Pt. #2's) right nose and lip area ..."
5. On 12/24/2024, the incident and follow-up reports for Pt. #2 was reviewed:
- On 12/9/2024 at 1:15 PM, the incident report and staff interviews indicated that while in the ED, Pt. #2 sustained laceration/bruising on Pt. #2's bottom lip while being redirected by two public safety officers (E #16 and E #17).
- On 12/11/2024, Pt. #2 reported to the hospital's Director of Behavioral Health Unit (E #8) that while in the ED (on 12/9/2024), Pt. #2 was beaten badly by the hospital's security/safety officer.
- On 12/12/2024, E #5's (Director of Quality and Risk) letter indicated that the hospital resolved Pt. #2's complaint/grievance.
6. On 12/24/2024, the hospital's schedule for public safety officers E #1, E #16, and E #17, was reviewed. E #1 worked night shift on 12/9/2024; was scheduled off on 12/10/2024; and then returned to work on 12/11/2024. E #16 continued to work at the hospital from 12/9/2024 through 12/13/2024 and E #17, from 12/9/2024 through 12/10/2024. There was no documentation that the security officer were suspended following allegations of abuse.
7. On 12/24/2024 at approximately 12:06 PM, an interview was conducted with E #5 (Director of Quality/Risk). E #5 stated that on 12/9/2024, E #5 received the incident report for Pt. #2. E #5 stated that due to the nature of the incident, there was a potential for patient abuse. On 12/9/2024, E #5 was not able to speak with Pt. #2. On 12/9/2024, E #5 stated that E #5 asked the two public safety officers if they physically assaulted Pt. #2. E #5 stated that while the investigation was ongoing, E # 16 and E #17 were not suspended, pending results of the investigation. E #5 stated, "The two public safety officers should have been suspended and removed from the area of services. I did not make (Pt. #2) aware of (Pt. #2's) right to notify the police."
Tag No.: A0169
Based on document review and interview, it was determined that for 1 of 2 (Pt #9) clinical records reviewed for restraints, the Hospital failed to ensure that a physician's order was not written as a standing [continuous] order.
Findings include:
1. On 12/23/2024, the hospital's policy titled "Restraint/Seclusion Policy (Reviewed May 2024)" was reviewed and required "...10. Non-violent or non-self-destructive patient - The order must be time limited not to exceed twenty-four (24) hours. A new order is required when the original order expires ...Evaluation and reassessment for continued need for restraint/seclusion ... ...11. Orders for restraint or seclusion must never be written as a standing order or on an as needed basis ..."
2. The clinical record for Pt # 9 was reviewed on 12/23/2024. Pt.#9 was admitted on 10/31/2024 for violent behavior and diagnosed with aggressive behavior/schizophrenia, agitation and right lower leg cellulitis [bacterial infection of the skin's deeper layers]. On 11/4/2024 at 7:50 AM, an order for restraints for Pt.#9 was ordered by Psychiatrist - MD#4. The order indicated a duration from 11/4/2024 7:50 AM to 11/19/2024 9:30 PM.
3. On 12/24/2024 at approximately 11:25 AM, an interview was conducted with the Executive Director of the Behavioral Medical Unit (E#8). E#8 stated that non-violent restraint orders are only good for 24 hours and should never be entered as a standing order.
Tag No.: A0174
Based on document review and interview, it was determined that for 1 of 2 violent restraint (Pt. #8) records reviewed, the Hospital failed to ensure that restraints were discontinued at the earliest possible time.
Findings include:
1. On 12/23/2024, the hospital's policy titled "Restraint/Seclusion Policy (Reviewed May 2024)" was reviewed and required " ...12 ...Restraint must be discontinued as soon as the individual meets the behavioral criteria for discontinuation ...Discontinuation of restraint and seclusion - 1. A patient may be released from restraints or seclusion before the expiration of the physician's order if, in the professional judgment of the nurse, the patient is no longer exhibiting violent or self-destructive behavior ..."
2. The clinical record of Pt.#8 indicated that Pt.#8 was admitted from [area hospital] for trying to start a fire with a diagnosis of schizoaffective disorder. On admission, Pt.#8 was anxious, irritable and impulsive. 4-point restraints every 2 hours was ordered for Pt.#8 from 10:30 PM on 12/10/2024 to 6:30 PM on 12/11/2024. The progress note by registered nurse (E#14) on 12/11/2024 at 8:30 PM, indicated that pt was removed from 4 point restraint at 8:30 PM and care provided.
3. The 24-hour restraint/seclusion flow sheet for the same period was reviewed and indicated that on 12/11/2024 at 3:15 AM to 8:00 AM - Pt.#8 behavior was marked as "S" - which indicated that the patient was sleeping and restraint may have been discontinued as required in the hospital's policy.
4. On 12/24/2024 at approximately 11:25 AM, an interview was conducted with the Executive Director of the Behavioral Medical Unit (E#8). E#8 stated that the restraint order can be discontinued by the registered nurse if in the nurses' professional judgment, it is safe to do so.